Chapter 31: Eating disorders - Management of eating and weight

Family response

-Family interactions not primary cause of eating disorders -Family interactions can be problematic (e.g. enmeshment, overprotectiveness, rigidity) -Parental attitudes - can influence body dissatisfaction

Reasons why eating disorders happen

Emotional Abuse Sexual Abuse Bullying Poor parental boundaries Family history of an eating disorder Reaction to taking stimulants

Eval/treatment outcomes, continuum of care and prevention of BN

Evaluation/Treatment Outcomes - better recovery outcomes than anorexia nervosa; improved with early detectio, research on effective treatments, and neuropharmacologic research and advances such as CBT. Continuum of Care - usually outpatient; recovery and support groups help prevent relapse Prevention - education for teachers, school nurses, parents and society - Box 31.12 p. 579; Website - girlshealth

Fam, RFs, teamwork and collab, priority for BN

Family may be chaotic, few rules, unclear boundaries; often enmeshed relationship mother/daughter Risk Factors - society's influences (media and peer pressure); body dissatisfaction; dietary restraint/over-exercising; sexual abuse - sequelae sets one up Teamwork and collaboration- goal is to stabilize and normalize eating (stop cycle, restructure thought patterns, teach healthy boundaries, and resolve conflicts about separation-individuation); Outpatient CBT and IPT; pharmacologic interventions; nutrition counseling Priority - suicide; self-mutilation; impulsive behaviors

Clinical course of BN

Few outward signs Normal weight Treatment can be delayed for years Appear overwhelmed and overly committed Have trouble setting limits and appropriate boundaries Lots of rules with food and food restrictions Feel shame, guilt and disgust Impulsive - e.g. spending

Nurs assess for BN

Teeth: enamel is worn off Callouses on the knuckles Must watch labs because of electrolyte imbalances: especially potassium (hypokalemia) Prone to 2 major medical complications: Mallory-Weiss tears of the esophagus and dilated cardiomyopathy

FYI for all EDs

With all eating disorders you are treating and screening for mood, anxiety, substance use disorder, suicidality, self-harm Preventing medical complications Helping to prevent relapse Psychoeducation about the disease process of an eating disorder

• anorexia nervosa

a mixture of symptoms that include significantly low body weight, intense fear of gaining weight or becoming fat, and a disturbance in experiencing body weight or shape (undue influence or distorted self-evaluation of body weight or shape or lack of recognition of the seriousness of low body weight).

• self-monitoring

accomplished using a diary in which the patient records binges and purges and precipitating emotions and environmental cues. Emotional and environmental cues are identified, and alternative responses are suggested, tried, and reinforced

bulimia nervosa

an eating disorder characterized by episodes of overeating, usually of high-calorie foods, followed by vomiting, laxative use, fasting, or excessive exercise

• enmeshment

an extreme form of intensity in family interactions and represents low individual autonomy in a family

• night eating syndrome

the individual eats after awakening from sleep or consumes an excessive amount of food after the evening meal

• refeeding

typically starts with 1500 calories a day and is increased slowly until the patient is consuming at least 3500 calories a day in several meals. The higher the initial number of calories prescribed has been demonstrated to influence a shorter length of hospital stay and recovery (Garber et al., 2016). The usual plan for patients with very low weights is a weight gain of between 1 and 2 lb a week. mood swings, pay attention to BG

STrengths assessment/therapeutic relationship

•Ask questions about motivation to eat differently •Determine if they want to have a more normal life Therapeutic Relationship: may be difficult initially; firm, accepting and patient approach; give rationales for approach; be consistent, nonreactive to power struggles

General about eating disorders and types

"Differ in definition, clinical course, etiologies and interventions..." Symptoms overlap between different eating disorders; subclinical cases; Types: •Anorexia Nervosa •Bulimia Nervosa •Other Specified Feeding and Eating Disorders •Unspecified Feeding and Eating Disorders BED - Binge Eating Disorder

Psychosocial mental health nurs interventions

1st step identify feelings (anxiety, fear, anger...); cognitive - restructure responses to cognitive distortions and unrealistic assumptions (see Box 31.2 - p. 577) use imagery, relaxation; psychoeducation - role of fats in diet, set realistic goals - see Box 31.9 p. 577; Wellness strategies - develop positive coping skills for stress management, sense of connection, and meaning of life

About BN epidemiology

All age groups Lifetime prevalence -2% Age of onset - 15-24 years Gender - females 10 times more likely than males Ethnicity - same as anorexia/ culture does affect the way women internalize the thin ideal Comorbidity - substance abuse, depression, and OCD

Summary of key points

Anorexia nervosa and bulimia nervosa have some common symptoms but are classified as discrete disorders. Eating disorders are best viewed along a continuum that includes subclinical or partial-syndrome disorders; because these disorders occur more frequently than full syndromes, they are often overlooked but, after they are identified, they can be prevented from worsening. Similar factors predispose individuals to the development of anorexia nervosa and bulimia nervosa, and these factors represent a biopsychosocial model of risk. These disorders are preventable, and identifying risk factors assists with prevention strategies. Etiologic factors contribute in combination to the development of eating disorders; no one factor provides an explanation. Treatment of anorexia nervosa frequently includes hospitalization for refeeding; bulimia nervosa is treated primarily on an outpatient basis. Cognitive-behavioral therapy and medication improve the symptoms. Individual and group interpersonal psychotherapy are also effective in self-evaluation and communication. The outcomes for bulimia nervosa are better than those for anorexia nervosa. The type and severity of comorbid conditions and the length of the illness influence outcomes. BED is characterized by periods of binge eating not followed by purging or any other compensating behaviors.

BN vicious circle

Binge Eating - rapid, episodic, impulsive, uncontrollable ingestion of a large amount of food in usually 1-2 hours Leads to: feelings of guilt, remorse, and self contempt Results in purging and dietary restraints (strict rules of eating) Treatment focuses on interventions related to dietary restraint Feeling "out of control" with food

Extra about BN

Binge and purge (compensatory weight loss) Laxative abuse, diuretic abuse Normal weight Comorbid: substance use disorder (especially stimulants or cocaine), Bipolar I, PTSD Can be fatal: esophagus rupture (mallory-weiss tear) and cardiac arrest bc hypertrophy

More about BED

Binge eating disorder: a lot of calories in a very short amount of time Binge eating disorder is not obesity Screen for depression, history of trauma Cardiac risk factors

Binge eating disorder (BED)

Binge in the same way as those with bulimia nervosa, but who do not purge or compensate for binges through other behaviors -Most are obese -Lower dietary restraint and higher in weight than those with bulimia -Binge eating, loss of control during binge, distress regarding binge, eating until uncomfortable full and then feelings of guilt or depression after -1.6% females; .8% males in US More research needed

Etiology of BN

Biologic - dieting may affect serotonergic regulation; binging may affect DA, Ach, and opioid reward-relating systems; genetic/family predispositions - some studies show genetic influences outweigh environmental; biochemical - low serotonin neurotransmission - depletion of tryptophan from dieting Psychological and Social Theories - converge; physical separation concerns; inability to set limits; overwhelmed feelings; teasing about weight; Cognitive theory - distorted thinking; family factors

Key concepts: body dissatisfaction body image distortion dietary restraint

Body dissatisfaction occurs when the body becomes overvalued as a way of determining one's worth. Body dissatisfaction is strongly related to low self-esteem Body image distortion occurs when the individual perceives his or her body disparately from how the world or society views it Dietary restraint has been described by researchers in the field of eating disorders as a way to explain the relationship between dieting and binge eating.

AN nurs assessment

Bradycardia and orthostatic hypotension Self-harm and/or increase in suicidality Watch labs Refeeding syndrome: as you reintroduce food, increased nutrition pushes the body into metabolic swings-especially blood sugar Increased risk for a heart attack Watch for over-exercising

Key concept: Emotional dysregulation

Changes in sensation are crucial constituents of emotional experiences and the intensity of perceived changes has been linked to emotional intensity and dysregulation for anorexia nervosa patients who report heightened sensory sensitivity and great emotional dysregulation. Weight restoration has been linked to an improved ability to cope with sensation (Lavender et al., 2015; Merwin et al., 2013). The emotional dysregulation model that links deficits in emotional regulation with anorexia nervosa posits that those with anorexia nervosa have deficits in the ability to understand and modulate emotions which results in individuals experiencing emotions as overwhelming and unmanageable (Haynos & Fruzzetti, 2011). Consequently those with anorexia nervosa use disordered eating to regulate their affective state by either reducing negative affect or increasing positive affect and thus disordered eating, through reinforcement, is maintained (Haynos, Roberto, & Attia, 2015). Emotion dysregulation comprises one's inability to accept one's emotional responses; to accomplish goals in the midst of distress and to be aware of and acknowledge the significance of developing and implementing coping strategies to influence and manage emotions effectively (Ruscitti, Rufino, Goodwin, & Wagner, 2016). Emotional dysregulation is hypothesized to relate to perfectionism. Treatment programs that address emotional regulation and focus on teaching skills to regulate emotions may therefore be effective especially with anorexia nervosa patients.

Key concepts: drive for thinness perfectionism

Drive for thinness is an intense physical and emotional process that overrides all physiologic body cues Perfectionism consists of personal standards (the extent to which the individual sets and tries to achieve high standards for oneself) and concern over mistakes and their consequences for their self-worth and others' opinions.

Recovery-oriented care -AN

Focus on nutritional rehabilitation, conflict resolution around body image disturbance, increase coping skills, address underlying conflicts, and assist family with healthy functioning and communication Hospitalization - medical (Box 31.6 - p. 572); suicidal Primary Care - treated due to medical concerns PRIORITY - mortality is high due to suicide and cardiopulmonary arrest

BN Dx criteria

Involves: recurrent episodes of binge eating, purging (e.g. vomiting, laxatives) and nonpurging compensatory behaviors (e.g. fasting, overexercising) *The difference between anorexia is the little or no weight loss Episodes - once a week/period of 3 months

Epidemiology/comorbidity for anorexia

Lifetime prevalence - 4% Age of Onset - 14 - 16; adolescents are vulnerable due to body image concerns, autonomy, peer pressure and media/ideal body type Gender - females are 10 times more likely than males Ethnicity/Culture - U.S. - slightly more common in Hispanic and white than African American/Asians Comorbidity - depression; risk for suicide; anxiety disorders are more strongly associated with AN

About AN

Males and females can have eating disorders especially anorexia Anorexia: significantly low body weight, severe restriction Comorbid: depression, anxiety, OCD, PTSD, personality disorders Restrict number of calories There is no such thing as too thin Significant body image distortion Rigid black and white thinking Anorexia can be fatal

Anorexia Nervosa (mix of symptoms and two types

Mixture of biopsychosocial symptoms - "include significantly low body weight, intense fear of gaining weight or becoming fat, and disturbance in experiencing body weight or shape" (White, 2018, p. 565) Two Types: •Restricting -not engaging in binge eating or purging behavior, but dieting and exercising •Binge-eat/purge - binge eating and misuse of laxatives, diuretics, or enemas Malnutrition/semistarvation result in preoccupation with food, binge eating, depression, obsession and apathy; may have several body systems compromised leading to medical complications and death

Bulimia nervosa

More prevalent that anorexia Usually people are older at onset than with anorexia Not as life threatening as anorexia Outcomes are better than for anorexia Mortality rates are lower than for anorexia

Anorexia nervosa etiology

Multidimensional - overlap of risk factors, causes, and symptoms Biologic Theories - alerted brain structure; genetic - first degree higher; hard to separate with environmental influences; neuroendocrine and neurotransmitter changes Psychological Theories - history - psychoanalytic paradigm; internalization of peer pressure; need to conform; body dissatisfaction (body is overvalued) Social Theories - conflicting messages; media, fashion industry, and peer pressure; obesity epidemic

Anorexia clinical course (how it goo: onset, subclinical, drive for thinness, emo dysreg)

Onset - early adolescent, can be slow Subclinical cases - may not be diagnosed Even if in "recovery" may still have distorted body image; preoccupied with weight and food; may develop bulimia or an anxiety disorder Drive for Thinness - overrides physiologic body cues; all-or-nothing thinking Emotional Dysregulation - heightened sensory sensitivity

Anorexia clinical course pt 2: perfectionism, guilt & anger, outcomes

Perfectionism - typical significant symptom of anorexia and bulimia; personality symptom risk factor Guilt and Anger - avoid conflict; "difficulty expressing negative emotions, especially anger" (p. 567) Outcomes - short-term are poor related to BMI, level of impulsivity, self-induced vomiting, and purging; if readiness for recovery are associated with positive outcomes, long-term outcomes better

BN nurs care = psychosocial assess, strengths assess, est a therapeutic rel

Psychosocial Assessment - cognitive distortions (cues or stimuli that lead to behaviors); knowledge deficits; "rules" - lead the way to destructive eating patterns; explore feelings of overwhelmed and powerless, ability to set boundaries, control impulsivity and maintain quality relationships; explore body dissatisfaction; evaluate for depression/mood disorders Strengths Assessment - when could they resist binging? What are their motivations? Establish a Therapeutic Relationship - nonjudgmental, accepting approach, stress importance of the relationship and outline its purpose

Risk factors and protective

Risk •Puberty •Low self-esteem, body dissatisfaction, and feelings of ineffectiveness •Bullying and weight teasing •Elite sports (disordered eating, menstrual dysfunction, and osteoporosis) Protective - healthy eating attitudes, accepting attitude toward body size, positive self-evaluation, and healthy parental relationships

binge eating disorder (BED)

binge w/o purging

EB nursing care for AN - Assessment

evaluation of body systems; history of symptoms; menses history; assess for behavioral responses (fear of weight gain, unrealistic expectations and thinking, and ritualistic behaviors); avoid conflict and difficulty expressing negative emotions; sexual fears/feelings of ineffectiveness - may use an instrument to measure; nonsuicidal self-injury; Eating Attitudes Test; Eating Disorder Examination Questionnaire; determine self-concept and self-esteem; Stress and coping patterns; social assessment

• purging disorder

frequent purging, but not binging. Individuals with this disorder purge at least once a week and have an intense fear of gaining weight or becoming fat

Nurs care for BN = phys health assess

hypokalemia (muscle weakness, fatigability, cardiac arrhythmias, palpitations, and cardiac conduction defects); electrolyte abnormalities; tooth enamel erosion; neuropsychiatric disturbances - poor concentration, attention; nurse should assess current eating patterns, number of times patient purges, and dietary restraint practices; sleep patterns; exercise habits

binge eating

rapid, episodic, impulsive, and uncontrollable ingestion of a large amount of food during a short period of time, usually 1 to 2 hours.

MEntal health nurs interventions

•Establish positive wellness habits of nutrition, physical activity, sleep, coping with stress and develop a support system. •Teach realistic goals around food and other activities •Refeeding (initial stage) - increase from 1,500 to 3,500 calories a day/ 1-2 pounds a week; weight increasing protocols - behavioral plan with positive reinforcements (may include nasogastric tube feedings); stabilize electrolyte balance; Promotion of sleep; pharmacologic - SSRIs - fluoxetine (Prozac)

BN Mental health nurs interventions: hospital, outpatient, med and CBT, behavioral techniques

•Hospital - meals and food intake are monitored; bathroom visits are supervised •Outpatient - record intake, binges, and purges; implement sleep hygiene strategies •Medication and CBT - best results; Fluoxetine - monitor for weight loss/purging Promote behavioral techniques - cue elimination and response prevention with self-monitoring; group interventions; psychoeducation - setting boundaries, healthy limits, develop assertiveness, learn nutritional concepts, clarify misconceptions about food; educate about binge-purge cycle, value of eating regularly, problems with laxatives...Box 31.14

Summary

•Know the difference in the different eating disorders and how they present •Know the nurse's role in assessment and providing nursing care •Read the "Summary of Key Points" on p. 589

Other eating disorders

•Overlap between obesity/overweight and eating disorders - continuum? •Overlapping symptoms: body dissatisfaction, loss of control over eating, dieting, unhealthy weight control behaviors, internalization of the cultural beauty ideal •Purging disorder - not binging; increased levels of body image distortions... Night Eating Syndrome - circadian modulation of food intake and sleep

Eval/continuum of care - poor outcomes, fam involv, discharge, outpatient, prevention

•Poor outcomes - long duration/low weight •Family involvement - improve outcomes •Discharged from hospital when 85% of ideal weight is achieved; need outpatient services •Outpatient - nutrition counseling/support; individual and family counseling; family and school interventions - Box 31.11 p. 578 Prevention - education for parents and children, screening, assessment and follow-up

Diagnostic criteria for anorexia

•Restriction of intake leading to significantly low body weight; BMI used for severity •Intense fear of gaining weight or becoming fat •"Body image issues including an undue influence of body weight on self-concept and lack of recognition of seriousness of low body weight"